Teens getting nicotine without smoking

Derek S. Brindisi, the regional health director, thought he had seen it all when it comes to nicotine-delivery products marketed to youths.

There are, of course, the electronic cigarettes that have been around for a little while. Then there are the flavored finely-grated tobacco-filled lozenges or strips that dissolve in the mouth. Two months ago, he saw his first electronic cigar in a local store. But, he was thrown for a loop when he saw a product called Nicogel, liquefied tobacco that is rubbed on the body to absorb the nicotine.

"You would be amazed at the things out there that tobacco manufacturers are trying to capture the minds of our youth," said Mr. Brindisi, who is director of the Worcester Division of Public Health and the Central Massachusetts Regional Public Health Alliance, which includes Worcester and the towns of Shrewsbury, Grafton, Millbury, West Boylston, Holden and Leicester.

Since states and the federal government began stepping up efforts to reduce smoking, cigarette and tobacco companies have been busy developing products that contain tobacco but are outside of the official definition of "tobacco products."

One of the latest appears to be snus, a moist tobacco product similar to chew and snuff. It is packaged like a small tea bag that is placed in the mouth and is more discreet than similar products because there is no need to spit. Some local health agents said they hear of students "snusing" all day because teachers and parents are unfamiliar with the product.

Mr. Brindisi said today, more high school students are using snus and other nicotine-delivery products versus cigarettes.

"Cigarette and tobacco manufacturers have reinvented themselves and have done a great job of trying to develop the next generation of users by inventing these new products to get around state and local regulations," said Mr. Brindisi. "That's really why we try to work very closely with boards of health throughout Central Massachusetts. We want them to know things have changed. It's still about smoking, but there are other things we need to be aware of."

The nicotine content of Ariva, a dissolvable, flavored tobacco tablet that looks like a candy mint, equates to six cigarettes, Mr. Brindisi said. And, some forms of snus have as much nicotine as 8 to 10 cigarettes.

Mr. Brindisi said he and other representatives of his office have been meeting with boards of health in the Worcester Regional Tobacco Control Collaborative, which covers 19 cities and towns, to educate them about cigarette-alternative products and give them tools they can add to local regulations as ways to prevent access to these products.

One strategy that has been proposed is increasing the price point of tobacco products. For instance, instead of allowing the general sale of a single item, such as a cigarillo, a small cigar, for 99 cents, stores could only sell a package of at least three.

"Data has found if you increase the price point of these items above $2.50, youth are less apt to purchase them," he explained.

Another suggestion is for communities to ban the sale of cigarettes and other tobacco products in pharmacies or drugstores.

Communities are also advised when they are amending local tobacco regulations to ban the sale of all nicotine-delivery products, including e-cigarettes, to anyone under the age of 21. Currently, the state law and most municipal regulations place the legal age at 18. To date, six municipalities have increased the legal age to 19; 11 others, including Hudson, have upped the age to 21. Mr. Brindisi said Grafton and West Boylston are looking at strengthening their tobacco regulations.

Several communities throughout the state, including 16 in Central Massachusetts, have banned the sale of electronic cigarettes to the sale of youth. Some have also banned their use by anyone anywhere the state's 2004 smoke-free workplaces and public places that the law extends to.

Sam S. Wong, Hudson Board of Health director, said it was an easy decision to raise the legal age to 21 for people to be able to purchase tobacco products. He pointed out that 10 percent of local high school students use tobacco products on a regular basis. And the town's lung cancer death rate between 2006 and 2010 was 49 per 100,000 people, a little lower than the state average of 49.7, but higher than the 44.1 regional rate.

Hudson's new regulation that goes into effect July 1, also requires cigars to generally be in an original package of at least four and sold for at least $5; bans the sale of blunt wraps, often used for smoking marijuana; and prohibits the sale of tobacco and nicotine-delivery products in pharmacies or drugstores and educational institutions.

Mr. Wong said he is optimistic that the new regulations will be effective, based on the results the town of Needham has seen since it became the first municipality in the state to change the legal smoking age to 21 in 2005. New York City, which increases to 21 the minimum age to purchase tobacco products beginning in May, modeled its regulation after Needham's. Needham was also one of the first municipalities in the country to ban smoking in the workplace and restaurants in the 1990s.

Janice E. Berns, director of public health in Needham, said the number of high school students who said they have smoked in the past month has dropped from around 13 percent in 2006 to about 5 percent in 2012. This was done before neighboring communities decided to raise their smoking age, she said. In addition, there has been a significant decrease in the lung cancer death rate, she said. While youths under 21 can go to another town to buy the products, it does make them less accessible.

"Looking at the data in Needham shows that it works," Mr. Wong said of delaying until 21 the age that a person can legally purchase tobacco products. "Sure, they can just go to a neighboring community to buy, but looking at Needham's data, even with those considerations, their (youth smoking and lung cancer) rates are still much lower than surrounding communities."

The tactics of cigarette and tobacco manufacturers to try to elude current regulations are in the radar of state and federal officials.

The Family Smoking Prevention and Tobacco Control Act President Barack Obama signed in 2009 requires a panel of experts to conduct a study on the public health implications of raising the minimum age to purchase tobacco products. The committee, created by the Institute of Medicine, held its first meeting last month. The report is required to be submitted to Congress by April 1, 2015. A spokesperson for the Food and Drug Administration said the agency also intends to propose a rule to regulate additional categories of tobacco products.

State Rep. Jeffrey Sanchez, D-Jamaica Plain, chairman of the Joint Committee on Public Health, has filed House Bill 3726 to amend the definition of "tobacco products" in the state law to include "any product containing, made, or derived from tobacco or nicotine that is intended for human consumption, whether smoked, chewed, absorbed, dissolved, inhaled, snorted, sniffed or ingested by any other means."

Mr. Sanchez said he filed the bill because the technology for nicotine delivery is moving more quickly than anyone expects. And, because the current state law does not address any of the new products. He said the bill is in the Joint Committee on Health Care Finance. But, he is considering filing his bill as an outside section of the state budget which will be discussed in the next few weeks. Like most people, even he had not heard of snus.

"Right now, we don't know about this product in terms of what it means to people's health. Instead of waiting to hear from the tobacco industry ... they said smoking and secondhand smoke were not a problem ... we need to address this as soon as possible," he said.